Screening Continues Even for Terminal Cancer Patients

by John Gever John Gever Senior Editor, MedPage Today
October 12, 2010

Action Points

Point out that, as a general rule, it should be considered inappropriate to order cancer screening tests in patients with advanced cancer and limited life expectancy.

Note that it is not clear if the tests were ordered by generalists, specialists, or at the request of patients.

Further note that one potential reason for over-ordering screening tests is that the tests may have been ordered prior to the diagnosis of advanced cancer -- and that inertia in the healthcare system tends to interfere with the capacity to reevaluate the need for these tests.

Many Medicare patients with advanced, poor-prognosis cancers still undergo routine screening with tests such as Pap smears, mammograms, cholesterol, and PSA tests -- despite the improbability of such tests being beneficial -- results of a large study showed.

For example, among Medicare beneficiaries with advanced pancreatic cancer, 13.9% of men underwent PSA testing, 18.3% of women had at least one screening mammogram and 5.4% had a Pap smear, and 18.3% of both sexes had cholesterol tests, according to a report in the Oct. 13 issue of the Journal of the American Medical Association.

Patients with advanced lung tumors and stage IV colorectal, breast, and gastroesophageal cancers underwent these screenings at similar rates, reported Camelia S. Sima, MD, of Memorial Sloan-Kettering Cancer Center in New York City, and colleagues.

"In an ideal healthcare system, healthcare practitioners would discontinue cancer screening for patients whose prognosis is too limited for the benefits of early detection to be realized," Sima and co-authors wrote.

The researchers obtained Medicare billing data on some 88,000 beneficiaries who had cancers reported to one of the CDC's Surveillance, Epidemiology, and End Results (SEER) registries from 1998 to 2005. Medicare charges that followed the date of diagnosis through 2007 were counted.

For comparison, the researchers also obtained billing data for about 87,000 Medicare enrollees without cancer, matched to individuals in each case group by age, sex, race, and area of residence.

In general, patients with such tumors received routine screening tests at roughly half the rate as the cancer-free controls. But Sima and colleagues highlighted the fact that sizeable numbers of the cancer patients -- most of whom would likely die within a year or two -- were still undergoing screening.

Among patients with any of these tumor types, they found the following rates for individual screening tests:

These rates did not vary much between individual cancer types, except that cholesterol testing was especially frequent among women with stage IV breast cancer (32.3% versus 54.5% of controls matched to those patients).

Sima and colleagues identified several factors associated with higher screening rates. Married patients and those who were relatively affluent were more likely to undergo screening. A history of receiving such tests in the past was an especially strong predictor that testing would continue despite an advanced-cancer diagnosis.

"The most plausible interpretation of our data is that efforts to foster adherence to screening have led to deeply ingrained habits," Sima and colleagues wrote.

"Patients and their healthcare practitioners accustomed to obtaining screening tests at regular intervals continue to do so even when the benefits have been rendered futile in the face of competing risk from advanced cancer."

On the other hand, they cautioned that their data did not allow for judgments about the necessity of screening in individual cases.

For example, they noted, "women with advanced breast cancer may sometimes live a number of years, making it somewhat more sensible for them to undergo screening."

They also observed that the impetus for screening -- oncologists, primary care physicians, or the patients themselves -- could not be ascertained from their data.

But irrespective of those limitations, Sima and colleagues argued that these data point to overdiagnosis and a needless burden on Medicare.

They suggested that steps could be taken to reduce screening tests given to patients with short life expectancies without prompting cries of "rationing" or interference in physician prerogatives.

"Identification of episodes of unnecessary care and strategies to curb them has the potential to be a win-win for patients, healthcare practitioners, and the public," the researchers offered.

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